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Prohibiting “body checking” in the youngest youth ice hockey leagues could significantly reduce head injuries and concussions in the youngest athletic leagues, according to a study conducted in leagues in two Canadian provinces, one where the practice is banned and the other where it is not.

Body checking is the intentional collision into an opponent to knock them down or into the walls of the skating arena.

Reported in the June 9 Journal of the American Medical Association, researchers found the rate of head injuries, notably concussions, among 11- and 12 year-old children was three times higher where body checking is permitted.

Led by Carolyn A. Emory, PhD, with the Sport Medicine Centre, Roger Jackson Centre for Health and Wellness Research, and the Faculty of Kinesiology at the Alberta Children's Hospital, the team looked at injuries over the 2007–2008 Pee Wee hockey season in Alberta, where the aggressive tactic is allowed, and in Quebec, where it is banned.

In a sample of 1,108 players in Alberta, they found 241 injuries, including 78 concussions, compared with 91 injuries and 23 concussions in Quebec, in a group of 1047 young players.

There are more than 500,000 registered youth ice hockey players in Canada, and some 340,000 in the US. Body checking has been linked to between 45 percent and 86 percent of injuries, the most common being concussion, which accounts for more than 15 percent of injuries in athletes under age 16.

The estimated absolute risk reduction (injuries per 1000 player-hours) that would be achieved if body checking — collision above the shoulders (head checking — were not permitted in Alberta was 2.84 (95 percent CI, 2.18-3.49) for all game-related injuries, 0.72 (95 percent CI, 0.40-1.04) for severe injuries, 1.08 (95 percent CI, 0.70-1.46) for concussion, and 0.20 (95 percent CI, 0.04-0.37) for severe concussion. There was no difference between provinces for practice-related injuries.

Injuries to the head or face were the most common severe injuries among the players, nearly double those of the knees, the next highest injury area. Smaller player size was associated with greater risk of head injury, as has been reported in other studies. There was a two-fold increase in intentional contact injuries of all kinds in Alberta youth leagues. According to the authors, this might be due to more aggressive on-ice behavior among players in leagues where body checking is allowed.

In both provinces, post-concussion physician follow-up visits were low. Among players who suffered confirmed concussions in Alberta, only half followed up with a physician. The rate was 60 percent in Quebec (14 of 23).

SIDELINE ASSESSMENTS

Robert Cantu, MD, chairman of the Department of Surgery, chief of neurosurgery and director of sports medicine at Emerson Hospital in Concord, MA, said the findings underscore a very basic premise in contact sports of all types and among players of all ages.

“If you reduce intentional aggressive contact, especially to the head and neck, you will lower the risk and rate of these injuries,” he told Neurology Today in a telephone interview.

Dr. Cantu, who is also clinical professor of neurosurgery and co-director of the Neurologic Sports Injury Center at Brigham and Women's Hospital in Boston, said efforts are under way to prohibit body checking in youth ice hockey, but change will be incremental, starting with banning head checking.

“We are taking baby steps in that direction already,” he said. “There's no place for head checking in juvenile leagues; it is simply unacceptable, and hopefully changes are coming.”

Dr. Cantu also noted that even the presence of physician observers and trained physical trainers on the sidelines at ice hockey games is no guarantee that players with head injures will receive adequate examinations for concussions. Also, young patients with head injuries are often referred to their personal doctor or pediatrician.

“Most pediatricians are not well trained in recognizing concussion symptoms, so hopefully they will use one of the standardized concussion symptom checklists that are available. There are several tools that we use.”

He cited the Standardized Assessment of Concussion (SAC) Tool, and recommendations contained in the consensus statement of the Third International Conference on Concussion in Sport, held in Zurich, Switzerland, published in 2009. (See “References” on page 15.)

AAN PRACTICE PARAMETER FOR CONCUSSION MANAGEMENT

The practice parameter presents a grading scale arrived at by a consensus of experts who reviewed all existing scales.

Grade 1:

* Transient confusion

* No loss of consciousness

* Concussion symptoms or mental status abnormalities on examination resolve in less than 15 minutes.

* Grade 1 concussion is the most common yet the most difficult form to recognize. The athlete is not rendered unconscious and suffers only momentary confusion (e.g., inattention, poor concentration, inability to process information or sequence tasks) or mental status alterations. Players commonly refer to this state as having been “dinged” or having their “bell rung.”

An injured athlete should be:

* Removed from contest.

* Examined immediately and at 5-minute intervals for the development of mental status abnormalities or post-concussive symptoms at rest and with exertion.

* They may return to play if mental status abnormalities or post-concussive symptoms clear within 15 minutes.

* A second Grade 1 concussion in the same contest eliminates the player from competition that day, with the player returning only if asymptomatic for one week at rest and with exercise.

Grade 2:

* Transient confusion

* No loss of consciousness

* Concussion symptoms or mental status abnormalities on examination last more than 15 minutes

* With Grade 2 concussion, the athlete is not rendered unconscious but experiences symptoms or exhibits signs of concussion or mental status abnormalities on examination that last longer than 15 minutes (e.g., poor concentration or posttraumatic amnesia). Any persistent Grade 2 symptoms (greater than 1 hour) warrant medical observation.

* A physician should perform a neurologic examination to clear the athlete for return to play after 1 full asymptomatic week at rest and with exertion.

* CT or MRI scanning is recommended in all instances where headache or other associated symptoms worsen or persist longer than one week.

* Following a second Grade 2 concussion, return to play should be deferred until the athlete has had at least two weeks symptom-free at rest and with exertion.

* Terminating the season for that player is mandated by any abnormality on CT or MRI scan consistent with brain swelling, contusion, or other intra-cranial pathology.

Grade 3:

* Any loss of consciousness, either brief (seconds) or prolonged (minutes). Grade 3 concussion is usually easy to recognize-the athlete is unconscious for any period of time.

An injured athlete should be:

* Transported from the field to the nearest emergency department by ambulance if still unconscious or if worrisome signs are detected (with cervical spine immobilization, if indicated).

* A thorough neurologic evaluation should be performed emergently, including appropriate neuroimaging procedures when indicated.

* Hospital admission is indicated if any signs of pathology are detected, or if the mental status of the athlete remains abnormal.

* If findings are normal at the time of the initial medical evaluation, the athlete may be sent home. Explicit written instructions will help the family or responsible party observe the athlete over a period of time.

* Neurologic status should be assessed daily thereafter until all symptoms have stabilized or resolved.

* After a brief (seconds) Grade 3 concussion, the athlete should be withheld from play until asymptomatic for 1 week at rest and with exertion.

* After a prolonged (minutes) Grade 3 concussion, the athlete should be withheld from play for 2 weeks at rest and with exertion.

* Following a second Grade 3 concussion, the athlete should be withheld from play for a minimum of 1 asymptomatic month. The evaluating physician may elect to extend that period beyond one month, depending on clinical evaluation.

* CT or MRI scanning is recommended for athletes whose headache or other associated symptoms worsen or persist longer than one week.

* Any abnormality on CT or MRI consistent with brain swelling, contusion, or other intracranial pathology should result in termination of the season and return to play in the future should be seriously discouraged.

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